Autonomy. Remember that bastion of medical ethics? The principle where we were supposed to respect ‘the right of competent adults to make informed decisions about their own medical care’?
The thing is, I’m not sure quite what happened to the big A. I feel like autonomy might have become rather like a sad old uncle who may have done some remarkable things during his career but now sits about spouting politically incorrect mumbo-jumbo. He has become an embarrassment, wouldn’t we rather he just kept quiet?
What do you think about autonomy in the present era? Should competent 18-year-olds be given the right to weigh up the pros and cons of a Covid vaccine, and decide accordingly if they would like to receive it? Competent 80-year-olds? Competent healthcare workers? Competent tennis players…?
Once you have effectively removed autonomy from one group (in a public health emergency), it becomes remarkably difficult to decide when to restore it.
If we were to mandate Covid vaccination, should we mandate childhood vaccines for schoolchildren? Should we mandate blood pressure tablets for hypertensives? Statins for hypercholesterolaemia? (Imagine trying!). You might scoff, but I’m sure pharmaceutical companies would be rather enthusiastic about the increased uptake of their products.
Studies suggest that Covid vaccinations may reduce transmission, at least for a period. But these are not double-blinded randomised controlled trials, and uncertainty must be acknowledged. For example, vaccinated groups are also likely to practise other infection control measures more carefully.
Covid vaccines are highly effective at reducing severe disease and hospitalisation. But the effect on reducing transmission, and the period over which there are benefits, is far less clear. The grounds therefore for mandating vaccines are shaky – it is difficult to argue that vaccination should not be a personal choice, so long as the health system is not overwhelmed.
I’ve tried to find a detailed quantification of my personal risk of hospitalisation or death, should I have a vaccine or a booster (and my medical history should also return to being none of your business, by the way). It is remarkably difficult to find this information. Surely the public ought to be able to quickly and easily find out what their comparative risks are? Have we also forgotten the importance of the ‘informed’ part of consent? The benefits of the vaccines are clearly more important for a 70-year-old diabetic than a healthy 18-year-old. If we are willing to be disingenuous about this, what else will we be disingenuous about?
Yes, I’m of the old-fashioned opinion that where there is a risk, there should be a choice. Bodily autonomy ought to be respected as far as is humanly possible.
We shouldn’t demonise those who would prefer not to be vaccinated. These are our patients, our neighbours, our care workers. They are also disproportionately from poorer socio-economic, and ethnic minority, groups – their reasons for hesitancy will often be complex (and sometimes reasonable). The unvaccinated deserve medical treatment (or a job), as much as any vaccinated person. People have previously been free to make unwise decisions, as long as they do not unduly harm those around them.
The pharmaceutical industry is not always completely transparent or even patient-centred. Once we introduce certain treatments by mandate (and in doing so, make a selection of people wildly rich), there is a risk we introduce a conflict of interest for the NHS or Government. Coercion may also serve to diminish patient trust in medical professionals: might we face a backlash with increased scepticism towards long-standing treatments and interventions?
In short, coercion is bad. These vaccines are good, for most people, in most circumstances. But we should persuade our patients, and staff, using a firm scientific basis, explaining why a vaccine may be in their best interests. We should never use shame, bullying, demonisation, misplaced fear, or threats.
Autonomy isn’t dead – but I think we might have wheeled him into the corner of the lounge, and ignored him for a little while.
Dr Katie Musgrave is a newly-qualified GP in Devon and quality improvement fellow for the South West